Biology of Tooth Movment

Biology of
tooth
movement
Dr Shalini Mohanty
2ND YEAR PGT
1
CONTENTS
Need of
History
understanding
Terminologies Physiological
Tooth
& Types movements
Theories &
clinical
considerations
NEED OF THE UNDRESTANDING
● The eruption and movement of a tooth occurs due to the translocation of the
tooth from one position in the jaw to another.
● Teeth can be repositioned and retained in a new position in the jaw using
orthodontic appliances, through the intervention of the cells of the
periodontium.
● Proper understanding of cellular and molecular biology will help design
mechanics that will produce maximum benefits during tooth movement with
minimal tissue damage.
Rabea, A.A., Future Dental Journal (2018), https://doi.org/10.1016/j.fdj.2018.05.001

3
Terminologies
Active eruption It is the actual movement of the tooth from its developmental site to its position in the
dental arch.
Passive eruption Does not involve tooth movement but occurs due to apical recession of gingival tissue
exposing more tooth structure
Tooth emergence when the tip of the crown of the tooth appears in the oral cavity by breaking through
the epithelium
Types of tooth movement

• Tooth Eruption
• Active
• Passive
• Lateral drifts
• Physiological
• Due to loss of adjacent teeth
• Orthodontic tooth movement
4
PHYSIOLOGIC
TOOTH
MOVEMENT
5
1. Tooth
eruption
6
● “It is the axial or occlusal movement of the tooth within and from its developing site through the
bone of the jaw and overlying mucosa to appear in the oral cavity and reach its functional position in
the occlusal plane .”
● To accomplish eruption, bone remodeling by osteoclasts (resorption of bone) and osteoblasts (bone
deposition) must take place in a coordinated manner.
● Most important is the removal of bone overlying the crypt, which forms the eruption pathway
Direction and type of tooth movement
Axial (occlusal) movement: It is an occlusal movement in the direction of the long axis of the tooth.
Eccentric growth movement refers to relative growth in one part of the tooth while the rest of the tooth
remains constant, the root elongates yet the crown does not increase in
size. As a result, the center of the tooth changes.
Rabea, A.A., Future Dental Journal (2018), https://doi.org/10.1016/j.fdj.2018.05.001 7

Types of tooth eruption in humans
These teeth are characterized by the eruption (occlusal

movement) of teeth with the investing tissues. In the
absence of periodontal disease, the teeth do not extrude if
further eruption occurs. In contrast to the other two types,
eruption does not occur by addition of tooth to the clinical
crown but, rather, by additions to the alveolar bone
8
Steedle and Profit The pattern and control of eruptive tooth movements Am J. Orthod lanuarl 87(1) 1985
Phases of tooth
eruption
9
10
Follicular growth, Preemergent Postemergent Juvenile occlusal Circumpubertal Adult occlusal
eruptive spurt eruptive spurt equilibrium occlusal eruptive equilibrium.
spurt,
deciduous teeth root formation eruptive rate slows slow movement in Between the ages of Throughout life
develop and erupt, continues as the as the tooth the occlusal 11 and 16 years the there is evidence of
the permanent tooth tooth begins a approaches the direction, which teeth in occlusion small increases in
follicles undergo period of rapid occlusal plane and increases the height begin a second lower facial height
sometimes eruption in the comes under the of the alveolar phase of active and continued
complicated occlusal direction’“, influence of processes eruption that lasts 2 eruption.2
migrations from their masticatory and to 3 years.
initial to their other intraoral
preeruptive forces
positions.“g
The tooth crypt eruption pursued a increase in lower Lower facial height
behaves as a cyst smooth course with facial height through increases on the
during this phase, an increasing rate additions to the order of 0.3 mm per
symmetrically as it approached alveolar height, year in the early
expanding vertically gingival emergence. ~OS,~~ 0.1 mm per
and mesiodistally. year by the age of
30,4, 4o and 0.02
mm per year as the
age of 70 is
approached,6
The eruptive spurt
slows as the face
reaches maturity
and a relative state
of equilibrium is re-
established by the
age of 18 years
11
Phases of Physiological tooth
movement or pattern of eruption
Pre-eruptive Eruptive
prefunctional Post-eruptive
phase
phase Functional phase
12
PRE ERUPTIVE TOOTH
MOVEMENT
● Starts – early bell stage Begin of root formation
● The movements of the developing and growing tooth germs within the alveolar process
before root formation.
● During this phase, the growing teeth move in various directions to maintain their
position in the expanding jaws.
● This is accomplished by both bodily movements and eccentric growth.
● These movements relate to the adjustments that each crown must make in relation to its
neighbor and to the jaw as they increase in width, height and length.

13
MOVEMENTS OF THE DECIDUOUS TOOTH GERMS
Increase in jaw length Anterior deciduous teeth drift forward and second
deciduous molar tooth germs drift backward.
Increase in jaw height Tooth germs move in vestibular direction (upward

or downward).
Increase in jaw width Tooth germs move (outward) facially.
14
Movement of permanent tooth germ
Incisors and canines Premolars Permanent molars
• preeruptive movements occur in an intraosseous location and are reflected in

the patterns of bony remodeling within the crypt wall.
• During bodily movement in a mesial direction, bone resorption occurs on the
mesial surface of the crypt wall, and bone deposition occurs on the distal wall
as a filling-in process.
• During eccentric growth, only bony resorption occurs, thus altering the shape
of the crypt to accommodate the altering shape of the tooth germ.
15
PREFUNCTIONAL ERUPTIVE
PHASE
● The eruptive phase begins with the onset of root formation and terminates
by tooth appearance in the oral cavity, just before function (pre-functional
phase)
● Tooth movements during eruptive phase are subdivided into:
INTRAOSSEOUS EXTRAOSSEOUS
16
• Intraosseous stage (1 to 10 µm/day) - at the
beginning of root formation
• Supraosseous stage (75 μm/day) - when the

erupting tooth moves occlusally through the bone
of the crypt and the connective tissue of the oral
mucosa, so that the reduced enamel epithelium
covering the crown comes into contact with the
oral epithelium
17
Mechanisms of Eruptive Tooth Movement
Numerous • Cushioned hammock theory
theories for • Root formation theory
• Vascular pressure/blood vessel thrust or
tooth hydrostatic pressure theory
eruption • Bone remodeling theory
• Dental follicle theory
have been • Periodontal ligament traction theory
proposed
18
Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based review article),Future Dental Journal,Volume 4, Issue 2,2018,
Cushioned hammock theory
● proposed by Harry Sicher

● This theory assumed that ligament (cushioned hammock ligament) below a tooth is
responsible for eruption
● The ligament described by Sicher was an artifact in slide preparation
19
Root formation theory
• reviewed by Massier and Schour, 1941
• Proliferating root encounters a fixed structure; and the apically
directed force is converted into a reactive occlusal force that causes
coronal movement of the erupting tooth
• In the intra-osseous stage of eruptive phase, root formation and jaw
growth lead to compressive coronal hydrostatic stress.
• This induces the dental follicle and stellate reticulum cells to secrete
mediators for bone resorption.
• Furthermore, the root formation would produce tensile apical
hydrostatic stress in the teeth germs that leads to bone deposition .
• Moreover, pre-occlusal eruption (supra-osseous stage of eruptive
phase) is completed by root growth and bone formation at crypt base
20
However, It is unlikely the cause of tooth eruption since:
● rootless teeth can erupt,
● some teeth erupt greater distance than the total root length; and the
● teeth erupt after completion of root formation or when the tissue forming the
root is removed
21
Vascular pressure/blood vessel thrust or
hydrostatic pressure theory
● Local increase in tissue fluid pressure in the periapical region is sufficient to move the
tooth
● However, this is debatable because root and local vasculature excision, does not prevent
tooth eruption
22
Bone remodeling theory
● Brash, 1928; Landsberger, 1924

● The inherent growth pattern of the mandible or maxilla
supposedly moves teeth by the selective deposition and
resorption of bone in the immediate neighborhood of the
tooth
23
Dental follicle theory
● The follicular theory postulates that the dental follicle
is capable of inducing, bone resorption above the
developing crown and bone apposition below it.
● This enables the formation of an eruptive path to
occur through which the tooth will be passively
conducted
● The receptor activator of nuclear factor kappa B
ligand (RANKL) gene is a marker gene for bone
resorption. Bone morphogenetic protein-2 (BMP-2)
gene is a marker for bone formation
24
● Eruption is regulated by inductive signals between the dental follicle, reduced enamel
epithelium (REE), stellate reticulum and alveolar bone
● Dental follicle produce Colony stimulating factor-1 (CSF-1)that stimulates
differentiation of osteoclast
● Stellate reticulum cells release of interleukin-1α (IL-1α) that stimulates the expression
of CSF-1 and monocyte chemotactic protein-1 (MCP-1).
● REE also secretes proteases that aid in creating an eruption pathway through
enzymatic digestion of collagens
● Epidermal growth factor (EGF) and transforming growth factor β 1 (TGF-β1)
released by the cells of the dental follicle enhance also the expression of CSF-1
● coronal bone resorption must be coupled with apical bone formation
● The expression of these BMPs is greatly enhanced by tumor necrosis factor–α (TNF-
α)
25
26
Periodontal ligament traction theory
● Suggested by Berkovitz and Thomas, 1969; Berkovitz, 1971

● This theory is based on the postulation that periodontal
ligament (PDL)-dental follicle complex possesses eruptive
force due to the traction power that fibroblasts have
● PDL fibroblasts connect to collagen fibers inserting into the
tooth's cementum so their occlusal migration pulls the tooth
toward the oral cavity
27
Recent theories of
eruption
28
Bite forces sensed by soft tissue dental
follicles theory
● This theory postulates that

follicular soft tissues detect bite-
forces and so direct bone
remodeling with the effect of
enabling tooth eruption
Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based

review article),Future Dental Journal,Volume 4, Issue 2,2018,
29
Innervation-provoked pressure theory
● It is hypothesized that tooth eruption depends on
(1)
Space in the pathway of eruption,
(2)
Pressure from below,
(3)
Adaptation of the periodontal membrane.
● The crown follicle creates the necessary space in the eruption path
● The root membrane functions as a glandular membrane. So, the
innervation causes overpressure that causes the tooth to elevate in
the eruption direction
● The adaptability of the periodontal membrane is essential for
eruption
Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based

review article),Future Dental Journal,Volume 4, Issue 2,2018,
30
●
The equilibrium theory
After the functional plane is reached, the eruption of the tooth is balanced in response to the growth
of the vertical growth of the mandible
● As the mandible grows vertically away from the maxilla the teeth have more room to erupt
occlusally in order to maintain occlusal contact with the opposing arch. This model of tooth eruption
reinforces the idea that postemergent tooth eruption, after reaching functional occlusion, is
controlled by forces impeding eruption, as opposed to encouraging forces. These balancing forces of
masticatory function and the soft tissue pressures from the lips, cheeks, and tongue are the rate-
limiting factors of postfunctional occlusal eruption
● The lasting eruptive movement that occurs while the teeth are free of contact, supports the idea that
eruptive control is based on the continuous force of the surrounding soft tissues
31
Neuromuscular theory or unification
theory
● The neuromuscular theory or unification theory of tooth eruption states that the
synchronized forces of the orofacial muscles, under the control of the central
nervous system, are responsible for the active movements of a tooth and the
molecular events prepared a pathway under the control of these forces
● The coordinated neuromuscular forces are converted into electrical,
electrochemical and biomechanical energies for the stimulation of cellular and
molecular activities within and around the dental follicle and enamel organ to
prepare a pathway as well as other cellular functions for eruption of a
developing tooth
32
changes that occur in tissues – Surrounding tissues Underlying tissues
overlying erupting teeth
• Degeneration of connective tissue • The surrounding fibers change from • As the tooth moves occlusally it
(decrease in blood vessels and being parallel to the tooth surface to creates space underneath the tooth to
degeneration of nerves) bundles that are attached to the tooth accommodate root formation
• Eruption pathway – altered tissue surface and extending towards the • Fibroblasts around the root apex form
area overlying the teeth periodontium (bone) collagen that attach to the newly
• Macrophages destroy cells and fibers • The periodontal ligament have formed cementum
by secreting hydrolytic enzymes contractile properties and changes • Bone trabeculae fill in the space left
• Gubernacular cord: The connective drastically during eruption behind as the tooth erupts in the
tissue overlying a successional tooth • During eruption, collagen fiber pattern of a ladder which gets denser
that connects with the lamina propria formation and turnover are rapid as the tooth erupts
of the oral mucosa by means of a enabling fibers to attach and release • After tooth reaches functional
strand of fibrous connective tissue and attach in rapid succession. occlusion periodontal fibers attach to
that contains remnants of dental • Some fibers may attach and reattach the apical cementum and extend into
lamina later while the tooth moves occlusally the adjacent alveolar bone
• Gubernacular canal: Holes noted in a as new bone forms around it and the
dry skull noted lingual to primary fibers will organize and increase in
teeth in jaws that represent openings number and density as the tooth erupts
of gubernacular cord As the
successional teeth erupt,
gubernacular canal widens enabling
tooth to erupt
33
The 6/4 rule for primary tooth emergence
Four teeth emerge for each 6 months of age
1. 6months: 4 teeth (lower centrals & upper centrals)
2. 12 months: 8 teeth (1. + upper laterals & lower laterals)
3. 18 months: 12 teeth (2. + upper 1st molars & lower 1st molars)
4. 24 months: 16 teeth (3. + upper canines & lower canines)
5. 30 months: 20 teeth (4. + lower 2nd molars & upper 2nd molars)
Rules of “sixes” in dental development

6 weeks old in utero: beginning of dental development
6 months old: emergence of the first primary tooth
6 years old: emergence of first permanent tooth
The rules of “Fours” for permanent tooth

At birth, four 1 st molars have initiated calcification
At 4 years of age, all crowns have initiated calcification
At 8 years, all crowns are completed
At 12 years, all crowns emerge
At 16 years, all roots are complete
34
Eruption rhythm
● Circadian eruption rhythm: during the early morning hours and day tooth stops
erupting and often intrudes slightly
● may be related to fluctuations of hormonal levels (late evening secretion of
growth hormone and thyroid hormone)that affect metabolic activities within the
periodontal ligament.
● It is also possible that a transient reduction in pressures by the cheeks, lips, and
tongue during periods of rest allows eruption to occur then.
Lee CF, Proffit WR. The daily rhythm of tooth eruption. Am J Orthod Dentofacial Orthop. 1995 Jan;107(1):38-47. doi: 10.1016/s0889-5406(95)70155-9. PMID: 7817960.
35
POST ERUPTIVE PHASE
● Made by the tooth after it has reached its functional position in the
occlusal plane
● Divided into three categories:
(1) movements to accommodate the growing jaws,
(2) those to compensate for continued occlusal wear,
(3) those to accommodate interproximal wear.
36
Accommodation for Growth
● readjustment of the position of the tooth socket

● formation of new bone at the alveolar crest and on the socket
floor to keep pace with the increasing height of the jaws
● readjustment occurs between 14 and 18 years of age
● The apices of the teeth move 2 to 3 mm away from the
inferior dental canal
37
Compensation for Occlusal Wear
● Tooth makes axial movement to compensate for the occlusal

wear
● achieved by continued cementum deposition around the apex
of the tooth
38
Accommodation for Interproximal
Wear
● This interproximal wear is compensated for by a process known as mesial or approximal
drift.
● The forces causing mesial drift are multifactorial and include
1) anterior component of occlusal force,
2) contraction of the transseptal ligament between teeth
3) soft tissue pressure.
Kronfeld’s theory states that there are neutral areas located in the following:
• Between the bicuspids in the maxilla
• Just mesial to the 1st molars in the mandible.
Based on that theory, the following conclusion can be drawn:
• Teeth anterior to the neutral area have a tendency to drift distally
• Teeth posterior to the neutral area have a tendency to drift mesially.
39
Anterior Component of Occlusal Force
● When teeth are brought into contact (e.g., in clenching the
jaws), an anteriorly directed force is generated.
● In a young dentition the anterior component of force, drives
the first premolars against the canines. The canines and
incisors all move in directions at right angles to the common
tangents drawn through the contact points
40
Contraction of the Transseptal
Ligament
● The suggestion has been made that its transseptal fibers

(running between adjacent teeth across the alveolar process)
draw neighboring teeth together and maintain them in contact
41
Soft Tissue Pressures
● The pressures generated by the cheeks and tongue may push
teeth mesially however soft tissue pressure does not play a
major role
● Resting tongue and lip pressures are known to be in the 5- to
15gm range,
42
2. Shedding
of Teeth
43
● Permanent incisors and canines develop lingually to the
deciduous teeth and erupt in an occlusal and vestibular
direction. Resorption of deciduous tooth roots occurs on the
lingual surface,
● Permanent premolars develop between the divergent roots of
deciduous molars and erupt in an occlusal direction. Hence
the resorption of interradicular dentin takes place with some
resorption of the pulp chamber, coronal dentin, and
sometimes enamel
44
deciduous teeth are completely formed
release of p53 gene
initiates a series of intracellular biochemical phenomena that lead to cytoskeleton breakage, as

well as cell nucleus and membrane degradation.
odontoblasts and cementoblasts die here and there, they leave the surface of deciduous teeth
with little, numerous, growing cell-free areas.
cementum and dentin receive and fix clasts in surface and cell-free areas,
triggering root resorption in deciduous teeth
45
Permanent tooth pericoronal follicle is rich in growth factors i.e epithelial growth factor
(EGF)
EGF molecules act in the surrounding bone tissue, inducing pericoronal bone
resorption
Formation eruption pathway
the process of resorption is established in deciduous roots and turned towards the
region of the permanent tooth to come.
46
47
Clinical
Implications
48
Ectopic Eruption
● Tooth does not follow its usual course
● Variation in position is influenced by various factors
Local traumatic Supernumerary

Fibrous tissue,
injury teeth,
Retained or
Arch length
prematurely lost
deficiency, and
deciduous teeth.
49
50
ETIOLOGY
Systemic (a) Hypothyroidisim,
Delayed Eruption
conditions (b) Hypopitutarism,
(c) Hypo-parathyroidism,
(d) Hypo-vitaminosis A and D,
(e) Calcium imbalance (osteoporosis)
● When the emergence timing

Local factors (a) Eruption cyst,
deviates significantly from the
(b) Dentigerous cyst,
established norms assigned to ethnicity
(c) and sex variety of odontogenic keratocyst (OKC),
Replacemental
(d) Ameloblastoma,
● Factors responsible: (e) Odontomes
(f) Premature loss of primary teeth
Genetic (a) amelogenesis imperfecta,

disorder (b) cherubism,
(c) cleidocranial dysplasia,
(d) ectodermal dysplasia,
(e) congenital hypertrichiosis lanugionosa,
(f) Gaucher disease
Drug induced (a) aspirin,

(b) acetaminophen,
(c) ibuprofen,
(d) Indomethacin,
(e) clodronate (Bisphosphonate).
Syndromes (a) Apert syndrome

associated (b) Down syndrome
(c) Turners syndrome
(d) Gardner syndrome
(e) Oculo-facial-cardio-dental syndrome
51
Cleidocranial dysplasia
● Resorption of primary teeth and bone is deficient
● Heavy fibrous gingiva and multiple supernumerary teeth
52
PRIMARY FAILURE OF ERUPTION
● In a rare but now well documented human syndrome called "primary failure of
eruption,“
●
● Affected posterior teeth fail to erupt, presumably because of a defect in the eruption
mechanism.
● Bone resorption apparently proceeds normally, but the involved teeth simply do not
follow the path that has been cleared.
● They do not respond to orthodontic force and cannot be moved into position.
● No associated systemic illness, no underlying endocrine dysfunction and no associated

genetic abnormality
53
Premature Eruption
● Teeth eruption before its stipulated time
According to Massler and Savara
Natal tooth Present at time of birth
Neonatal teeth Erupt into oral cavity within 30
days of life
Spoug and feasby

classification
Based on the Based on

degree of maturity appearance
Unerupted – tooth
Immature (edema of the Eruption of just a
Mature Shell-shaped crown Solid – crown (little
natal/neonatal gingival tissue but portion of the tooth
natal/neonatal tooth (absence of root) or no crown)
tooth. the tooth is (incisal margin).
palpable)
54
ETIOLOGY
Genetic causes • Hereditary transmission of an

autosomal dominant gene (Msx 1
and Msx 2 gene)
• mutation of this particular gene
causes premature primary tooth
eruption.
Endocrine causes Increase in the secretion of pituitary

hormones including thyroid and
androgens.
Infectious causes Syphilis
Malnutrition Nutritional deficiency during pregnancy
55
56
Impacted Teeth
These teeth cannot erupt due to a physical barrier preventing their eruption. Mandibular third
molars are the most commonly impacted teeth. The incidence of primary tooth impaction is
twice as common in the mandible as in the maxilla and the most commonly affected teeth are
mandibular second molars
Embedded Teeth
These teeth with no physical obstruction in their path remain unerupted due to la ack of
eruptive force.
Submerged Teeth
Submerged teeth are those that, after the eruption, ankylose and lose their ability to
maintain the continuous eruptive potential as the jaws grow
57
Detrimental Habits that Affect Tooth
Eruption Digit Sucking
● This habit affects the eruption path of maxillary incisors
resulting in their protrusion due to the disturbance in the
balance between the outward force of the tongue musculature
on the palate and the inward force of the cheek musculature.
Tongue Thrust
● In children with tongue thrust habit, greater outward force by
the tongue musculature is applied, resulting in a change in the
eruption pathway of maxillary incisors.
Lip Habit
● Sucking or biting the lips, particularly the lower lip, results in
more significant inward pressure by the lip musculature,
which in turn leads to a change in the eruption path of the
mandibular incisors.
58
REFERENCES
● Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based review
article),Future Dental Journal,Volume 4, Issue 2,2018,
● Pages 189-196,Hanisch et al. Head & Face Medicine (2018) 14:5
● Steedle and Profit The pattern and control of eruptive tooth movements Am J. Orthod lanuarl
87(1) 1985
● Lee CF, Proffit WR. The daily rhythm of tooth eruption. Am J Orthod Dentofacial Orthop. 1995
Jan;107(1):38-47. doi: 10.1016/s0889-5406(95)70155-9. PMID: 7817960.
● Rabea, A.A., Future Dental Journal (2018)https://doi.org/10.1016/j.fdj.2018.05.001
THANK
YOU.
ORTHODONTIC
TOOTH
MOVEMENT
61
● Orthodontic tooth movement differs markedly from physiological dental drift
or tooth eruption. The former is uniquely characterized by the abrupt creation
of compression and tension regions in the PDL
● Orthodontic tooth movement (OTM) is the result of externally applied forces
on a complex biological system that contains the alveolar bone, the periodontal
ligament (PDL), the tooth, and the gingiva.
krishnan V, Davidovitch Z, editors. Biological mechanisms of tooth movement: Second edition. Chichester, UK: John Wiley & Sons, Ltd; 2015. 62
Entities important for tooth movement
Cells
Fibroblast
Osteoblasts
Extracellular matrix
Osteoclasts
Cementoblasts
Macrophages
Extracellular matrix
● Principal component - fibers, embedded in a gel‐like ground substance
● Predominant type of fiber in the alveolar bone, the PDL, and the root cementum is collagen type I,
● A second type of fiber in the PDL is the oxytalan fiber
● The ground substance is primarily composed of water and large organic molecules, such as
glycosaminoglycans (GAGs), including hyaluronic acid, heparan sulfate, dermatan sulfate, and chondroitin
sulfate
● the fibrous components are embedded in the “ground substance”, a network of proteoglycans, such as heparan
sulfate, dermatan sulfate, and chondroitin sulfate, consisting of a core protein covalently bound to GAG chains
● The viscoelastic characteristics recorded for the PDL essentially result from interactions between unbound
fluid and the compressible visco ‐elastic porous matrix that makes up the bulk of the ground substance.
● Proteoglycans of the ground substance also bind to fibrous matrix proteins, such as collagen and oxytalan
● Together, these components form the ECM, which acts as a substrate for PDL cells and allows them to migrate
and to communicate with each other
● PDL contains extensive vascular and neural systems.
● Blood vessels in PDL may help in mechanical suspension and support of the
tooth and supply surrounding PDL.
● The neural system in the PDL contains free and specialized nerve endings
● The Ruffini‐like endings are mainly present near the root apex and secrete
various neuropeptides, such as calcitonin gene‐related peptide (CGRP) and
substance P. The coiled type endings are mainly located in the mid‐region of
the PDL. Both act as mechanoreceptors and as fast acting nociceptors
Cells
FIBROBLAST
● major cell type

● responsible for the synthesis and secretion of all the elements
of the ECM
● synthesize and secrete a wide variety of regulatory molecules
that act as local signals for the adaptation of the tissue to
changing conditions
OSTEOBLAST
● They originate from the mesenchymal stem cells of the bone marrow,
endosteum, periosteum, and perivascular pericytes
● The osteoblasts synthesize and secrete the collagen and noncollagen
proteins, such as osteocalcin and osteopontin, that form the organic bone
matrix or osteoid material
● they express alkaline phosphatase (ALP), which is essential for the
mineralization of the osteoid
● Osteoblasts also produce and secrete hydroxyapatite into the osteoid,
forming the strong and well‐organized mineralized matrix of the bone
OSTEOCLAST
● derived from extravasated monocytes

● responsible for the resorption of bone.
● formation of an effective seal around the resorption compartment enables the
formation of an isolated compartment between the bone and the cell, called
Howship’s lacuna
CEMENTOBLAST
● derived from the mesenchymal dental follicle.

● They cover the root surface and are responsible for
cementogenesis
MACROPHAGES
• Macrophages are a type of white blood cells that originate

from extravasated monocytes
• essential as phagocytes in defense against pathogenic
microorganisms, in clearance of dead or senescent cells, and
in removal of cell debris.
Biomechanical characteristics of the PDL
cells communicate with one
movement of fluids
another through the liberation of
in the extracellular
specific molecules called
matrix
chemokines and cytokines
General regulatory mechanisms
CELL–CELL INTERACTIONS
● allow cells to communicate with each other in response to changes in their microenvironment
● They can also be variable, through the binding of soluble proteins secreted by one cell to receptor
proteins on another cell.
● autocrine actions - cells communicate with adjacent cells
● paracrine actions - cells communicate with nearby cells
● For Orthodontic Tooth Movement(OTM) , autocrine and paracrine interactions are essential
● Two groups of local regulatory proteins are distinguished, namely growth factors and cytokines.
● The most important factors involved in bone remodeling and thus in OTM belong to the transforming
growth factor‐β (TGFβ) super family including TGFβs and bone morphogenetic proteins (BMPs),
epidermal growth factors (EGF)
● For OTM, the most important regulatory molecules is formed by the prostaglandins, which are formed
through the activity of cyclooxygenases (COX1 and COX2) and prostaglandin synthase
CELL– MATRIX INTERACTIONS
most important for

OTM
Focal adhesions as well as the cytoskeleton are constantly

remodeled
krishnan V, Davidovitch Z, editors. Biological mechanisms of tooth movement: under
Second edition. the
Chichester, UK:influence of the
John Wiley & Sons, ECM
Ltd; 2015. 72
Effects of orthodontic force
application
73
Phases of Orthodontic Tooth Movement
In 1962, Burstone suggested that, if the rates of OTM were
plotted against time, there would be three phases of OTM
Initial phase period of very rapid movement, which occurs

immediately after application of force to the tooth. This
rate is attributed to the displacement of the tooth within
the PDL space and bending of the alveolar bone
Lag phase no or low rates of tooth displacement occur. This lag
results from hyalinization of the PDL in areas of
compression. No further tooth movement will occur until
cells complete the removal of all necrotic tissues
Post lag phase the rate of movement gradually or suddenly increases.
● According to van Leeuwen et al (1999) and Von Böhl, et al.(2004) – 4 phases
First phase • lasts 24 hours to 2 days

• movement of the tooth inside its bony socket, causing structural changes
in the ECM
• the ECM is compressed in the direction of the tooth movement, leading to
a temporal increase in tissue pressure, constriction of blood vessels, and
deformation of nerves.
Second phase where there is an arrest in tooth movement lasting for approximately 20–30
days. As long as the hyalinized tissue remains, tooth movement is prevented
Third phase, begins with an increasing rate only after the complete removal of the
hyalinized tissue.
Fourth phase tooth movement takes place at a constant rate, as long as the force is
exerted and no obstacles are encountered
Cell biological processes during initial
phase and hyalinization
rapid reallocation of fluid,
first few seconds -

blood vessels in the PDL are occluded, causing hypoxic conditions
10 μm/s
cell death through the loss of cell membrane integrity and an uncontrolled release of organelles and debris into
subsequent 20
the ECM
At the trailing side of the tooth, the very fast initial movement of the tooth seconds - 1μm/s
leadsresponse
to a rapid influx Then, - 0.1 μm/s or
Initiate an inflammatory through theof fluidofininflammatory
action the first few seconds.
mediators Inas
such theinterleukin
subsequent
‐1β (IL ‐1β)
hours, widening of the blood vessels and tensioning of the collagenous
and PGE2 in the surrounding tissue less
fibers are seen. During the hyalinization phase, the situation at the trailing
attract leukocytes and nearby phagocytes, such as macrophages and foreign body giant cells to eliminate the
side remains stable
dead cells and debris by phagocytosis
ECM changes by protein denaturation
a gelatinous (gel‐like, hyaline) substance is formed called hyalinization and is mediated by enzymes from the
matrix metalloproteinase family (MMP‐1, MMP ‐8, MMP ‐13)
osteoclasts migrate to the area from nearby marrow spaces, after having resorbed the bone immediately
adjacent to the necrotic PDL area, in a process known as undermining resorption
OTM becomes only possible after all necrotic tissue has been removed. 76
krishnan V, Davidovitch Z, editors. Biological mechanisms of tooth movement: Second edition. Chichester, UK: John Wiley & Sons, Ltd; 2015.
Cell biological processes during real
tooth movement LEADING SIDE
removal of the necrotic tissue
influx of differentiating fibroblasts, which secrete new ECM
restore the vasculature of the PDL through VEGFs
tooth is again surrounded by a vital PDl
The integrins by which they are attached to the ECM can act as force transducers
fluid flow induces strain in the cell membranes, of fibroblasts osteoblasts and the osteocytes.
the activation of cells by integrin‐mediated strain transmission to the cytoskeleton and the subsequent induction of the
expression of a variety of growth factors and cytokine
These factors, such as FGF, IGF‐1, IL ‐1α, IL ‐1β, IL ‐6, and TNFα mediate the differentiation of precursors into osteoblasts
and osteoclast 77
● For OTM, resorption of the alveolar bone by osteoclasts at the leading side of the tooth is essential
● These cells are derived from myeloid precursors that have differentiated into monocytes and subsequently into
osteoclast precursors through macrophage colony ‐stimulating factor (M ‐CSF)
● Their further differentiation is dependent on the ligand for the receptor activator of nuclear factor kappa ‐B
(RANKL) that is secreted by fibroblasts and osteoblasts.
● The differentiation of osteoclasts is counteracted by osteoprotegerin (OPG)
● strain affects both the secretion of RANKL and the secretion of OPG
● At the leading side of the tooth the negative strain stimulates the secretion of RANKL, but decreases the secretion
of OPG, and thus the differentiation and functioning of osteoclasts are stimulated. On the other hand, in the areas
with positive strain, the trailing side of the tooth, RANKL as well as OPG are upregulated, but OPG is more
upregulated than RANKL, and thus osteoclast differentiation is prevented
TRAILING SIDE
the PDL is widened, accompanied with a positive strain in the ECM and an acute inflammatory reaction
This results in an increase in IL ‐1β, IL‐10, PGE2, and TGF‐β expression
increase in OPG and a decrease in RANKL secretion by the osteoblasts and periodontal fibroblast
secretion of collagen type I and collagen type III, as well as the formation of new Sharpey’s fibers
Simultaneous deposition of the Sharpey’s fibers and new bone matrix on the adjacent alveolar bone socket wall, anchoring
the Sharpey’s fibers in the bone matrix
FGF-2 and VEGF, growth factors involved in the development of vascular elements, are upregulated
formation of new ECM and bone deposition is stimulated, and adaptation of the vascular system to the new situation is induced.
81
Theories of tooth
movement
82
The pressure-tension theory
● Sandstedt (1904), Oppenheim (1911), and Schwarz (1932) hypothesized that a tooth
moves in the periodontal space by generating a “pressure side” and a “tension side”.
● Pressure side, the PDL displays disorganization and diminution of fiber production.
Here, cell replication decreases seemingly due to vascular constriction
● Tension side, stimulation produced by stretching of PDL fiber bundles results in an
increase in cell replication. This enhanced proliferative activity leads eventually to an
increase in fiber production.
● The width changes in the PDL cause changes in cell population and increases in cellular
activity.
● bone remodeling consists of loss of bone mass at PDL pressure areas and apposition at
tension areas.This succession of events formed the central theme of the pressure-tension
hypothesis.
Rohit Reddy S Gowri sankar Singaraju Prasad MandavaVivek Reddy Ganugapanta BIOLOGY OF TOOTH MOVEMENT Annals and Essences of Dentistry VII (4);2015 83
Fluid Dynamic theory
● Given by Bien in 1966

● Tooth movement occurs as a result of alterations in fluid dynamics in periodontal
ligament
● Periodontal space is a confined space and passage of fluid in and out of this space is
limited
● A hydrodynamic condition is created that resembles a hydraulic mechanism and a shock
absorber.
● This results in reduced oxygen level on the compression side, escaping of blood gases
into interstitial fluid creating a favorable environment for resorption.
The bone-bending theory
● Farrar was the first to suggest, in 1888

● when an orthodontic appliance is activated, forces delivered to the tooth are
transmitted to all tissues near force application. These forces bend bone,
tooth, and the solid structures of the PDL
● In 1962, Bassett and Becker proposed that, in response to applied mechanical
forces, there is generation of electric potentials in the stressed tissues.
● The concave side of orthodontically treated bone is electronegative and
favors osteoblastic activity, whereas the areas of positivity or electrical
neutrality—convex surfaces—showed elevated osteoclastic activity
Pathways of tooth movement
● Mostafa et al proposed an integrated hypothetical model for tooth movement
which consisted of 2 pathways—I and II—
Pathway I
● orthodontic force creates vectors of pressure and tension, leading to bone
bending, generation of tissue bioelectric polarization, and subsequent bone
remodeling
● prostaglandin synthesis
● these phenomena, along with membrane electrical polarization by piezoelectric
processes, act on the cell surface cyclic nucleotide pathway, generating changes
in the levels of intracellular second messengers.
● alterations in cell proliferation, differentiation, and activation
Pathway II
● inflammatory response after force application
● Lymphocytes, monocytes, and macrophages invade these
tissues, enhancing prostaglandin release and hydrolytic
enzyme secretion
● local elevation in prostaglandins and a subsequent increase in
cellular cAMP concentrations increase osteoclast activity.
● hydrolytic enzymes, such as collagenase, dissolve the
mechanically strained ECM.
Tissue reactions with varied force
applications
Continuous force Interrupted force Intermittent force
● Most contemporary fixed orthodontic appliances use light continuous forces as part of orthodontic mechanotherapy to effect tooth
movement.
● continuous force can subside rapidly and thus be interrupted after a limited period of time
● This kind of a force, that starts in a continuous mode and then becomes interrupted, is biologically favorable, particularly when its
initial magnitude is low
● hyalinized zones might develop in sites of compressed PDL, but, as soon as this necrotic tissue is eliminated and the tooth moves,
the force decreases quickly.
● This rest period between appliance activations is the time used by the tissues for reorganization
● This promote favorable cell proliferation for further tissue changes when the appliance is activated again
Optimal orthodontic force
● The concept of OOF in orthodontic treatment was first raised
by Schwarz in 1930s, who proposed Optimal Orthodontic
Force to be the force resulting in pressure similar to capillary
vessel blood pressure
● optimal orthodontic force (OOF) is a force that has to be
large enough to overcome the friction within the appliance
system so as to exert pressure on the periodontal ligament
(PDL), but not too large to cause the so-called hyalinization
or sterile necrosis of PDL,
● It has been suggested that the force of approximately 15-
30gm/cm2
90
91
ADVERSE EFFECTS OF ORTHODONTIC
FORCE
Root resorption
● The magnitude of an orthodontic force and rigid fixation of
the archwire to the brackets could be considered the most
important factors predisposing a tooth to the root resorption
● Maxillary central incisors, are the most prone to the process,
followed by the maxillary molars and the canines
Gingival problems
● Fixed-appliance orthodontics has been shown to produce

deleterious effects on the periodontium, ranging from
gingivitis to bone loss
● This response is mainly due to plaque accumulation and the
proximity of these attachments to the gingival sulcus
Pain
● OTM causes inflammatory reactions in the periodontium and dental pulp

● release of various biochemical mediators
● Periodontal pain is caused by a process involving the development of
pressure, ischemia, inflammation, and edema.
● Pain begin a few hours after the application of an orthodontic force and last
for approximately 5 days
● Painful sensations result, in part, from the stretching and distortion of
tissues by the mechanical loads as well as from interactions of multiple
inflammatory mediators with local pain receptors
Pulpal reactions
● Periodontal and pulpal blood flow increased
● Römer et al. (2014) showed the induction of hypoxia in dental pulp after OTM
which leads to an inflammatory response inside treated teeth.
● Rana et al. (2001) found apoptosis in dental pulp tissues of rats undergoing
orthodontic stress
● Perinetti et al demonstrated that an enzyme, aspartate aminotransferase (which is
released extracellularly upon cell death), is significantly elevated after orthodontic
force application
● It was concluded that orthodontic force might stimulate vasodilatation in dental
pulp tissues
Mobility
● Mobility is due to widening of PDL space and temporary

disorganization of the fibers in the PDL
● Heavier Force causes greater degree of undermining
resorption which leads to excessive mobility.
● If the tooth becomes extremely mobile, force should be
discontinued until the mobility decreases to moderate levels
● Excessive mobility will usually correct itself without
permanent damage.
EFFECT OF DRUGS
NSAIDs Inhibition of the inflammatory reaction produced by PGs slows the

tooth movement
Aspirin decreases bone resorption by inhibition of PGs’ synthesis and may
effect differentiation of osteoclasts from their precursors.
Acetaminophen (Paracetamol) a weak COX-1 and COX-2 inhibitor that also reduces urinary
prostaglandin levels after systemic administration and has shown no
effect on orthodontic tooth movement
Vitamin D caused increase in the number of osteoclasts and amount of tooth
movement as and increased bone formation on the pressure side of
the periodontal ligament
Fluorides increases bone mass and mineral density hence may delay
orthodontic tooth movement and increase the time of orthodontic
treatment
Bisphosphonates rise in intracellular calcium levels in osteoclastic-like cell line,
reduction of osteoclastic activity, prevention of osteoclastic
development from hematopoietic precursors, and production of an
osteoclast inhibitory factor and inhibit orthodontic tooth movement
: Diravidamani K, Sivalingam SK, Agarwal V. Drugs influencing orthodontic tooth movement: An overall review. J Pharm Bioall Sci 2012;4:299-303.
97
EFFECT OF HORMONES
Estrogens inhibits the production of various cytokines which are involved in bone resorption by
stimulating osteoclast formation and osteoclast bone resorption hence decrease the
velocity of tooth movement
Androgens inhibit bone resorption, modulate the growth of the muscular system, and may affect
the length and results of the orthodontic treatment
Thyroid hormones increased bone remodeling, increased bone resorptive activity and reduced bone
density hence increases the speed of orthodontic tooth
Relaxin accelerate the early stages of orthodontic tooth movements
Calcitonin inhibits bone resorption by direct action on osteoclasts and stimulates the activity of
osteoblasts. It is considered to inhibit the tooth movement
Parathyroid hormone PTH affects osteoblasts’ cellular metabolic activity. Its effects on osteoclasts occur
through the production of RANK-L
PTH could induce an increase in bone turnover that would accelerate orthodontic tooth
movement
: Diravidamani K, Sivalingam SK, Agarwal V. Drugs influencing orthodontic tooth movement: An overall review. J Pharm Bioall Sci 2012;4:299-303.
98
REFERENCES
● Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based review
article),Future Dental Journal,Volume 4, Issue 2,2018,
● Pages 189-196,Hanisch et al. Head & Face Medicine (2018) 14:5
● Steedle and Profit The pattern and control of eruptive tooth movements Am J. Orthod lanuarl
87(1) 1985
● Lee CF, Proffit WR. The daily rhythm of tooth eruption. Am J Orthod Dentofacial Orthop. 1995
Jan;107(1):38-47. doi: 10.1016/s0889-5406(95)70155-9. PMID: 7817960.
● Rabea, A.A., Future Dental Journal (2018)https://doi.org/10.1016/j.fdj.2018.05.001
● Diravidamani K, Sivalingam SK, Agarwal V. Drugs influencing orthodontic tooth movement: An
overall review. J Pharm Bioall Sci 2012;4:299-303
● krishnan V, Davidovitch Z, editors. Biological mechanisms of tooth movement: Second edition.
Chichester, UK: John Wiley & Sons, Ltd; 2015.
99
THANK
YOU.
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Biology of Tooth Movment

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Biology of

Rabea, A.A., Future Dental Journal (2018), https://doi.org/10.1016/j.fdj.2018.05.001

Types of tooth movement

Direction and type of tooth movement

Rabea, A.A., Future Dental Journal (2018), https://doi.org/10.1016/j.fdj.2018.05.001 7

These teeth are characterized by the eruption (occlusal

Rabea, A.A., Future Dental Journal (2018), https://doi.org/10.1016/j.fdj.2018.05.001

Increase in jaw height Tooth germs move in vestibular direction (upward

Increase in jaw width Tooth germs move (outward) facially.

Incisors and canines Premolars Permanent molars

• preeruptive movements occur in an intraosseous location and are reflected in

• Supraosseous stage (75 μm/day) - when the

● proposed by Harry Sicher

● Brash, 1928; Landsberger, 1924

● Suggested by Berkovitz and Thomas, 1969; Berkovitz, 1971

● This theory postulates that

Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based

Amany A. Rabea,Recent advances in understanding theories of eruption (evidence based

Rules of “sixes” in dental development

The rules of “Fours” for permanent tooth

● readjustment of the position of the tooth socket

● Tooth makes axial movement to compensate for the occlusal

● The suggestion has been made that its transseptal fibers

release of p53 gene

initiates a series of intracellular biochemical phenomena that lead to cytoskeleton breakage, as

triggering root resorption in deciduous teeth

Formation eruption pathway

Local traumatic Supernumerary

● When the emergence timing

Genetic (a) amelogenesis imperfecta,

Drug induced (a) aspirin,

Syndromes (a) Apert syndrome

● No associated systemic illness, no underlying endocrine dysfunction and no associated

Spoug and feasby

Based on the Based on

Genetic causes • Hereditary transmission of an

Endocrine causes Increase in the secretion of pituitary

Infectious causes Syphilis

Malnutrition Nutritional deficiency during pregnancy

● major cell type

● derived from extravasated monocytes

● derived from the mesenchymal dental follicle.

• Macrophages are a type of white blood cells that originate

most important for

Focal adhesions as well as the cytoskeleton are constantly

Initial phase period of very rapid movement, which occurs

First phase • lasts 24 hours to 2 days

first few seconds -

ECM changes by protein denaturation

removal of the necrotic tissue

influx of differentiating fibroblasts, which secrete new ECM

restore the vasculature of the PDL through VEGFs

tooth is again surrounded by a vital PDl

This results in an increase in IL ‐1β, IL‐10, PGE2, and TGF‐β expression

● Given by Bien in 1966

● Farrar was the first to suggest, in 1888

● Fixed-appliance orthodontics has been shown to produce

● OTM causes inflammatory reactions in the periodontium and dental pulp

● Mobility is due to widening of PDL space and temporary

NSAIDs Inhibition of the inflammatory reaction produced by PGs slows the